indications for laser peripheral iridotomy. indications: 1. pupillary block. phakic. aciol....

INDICATIONSFOR LASER

PERIPHERAL IRIDOTOMY

Duc Tran

FINANCIAL INTERESTS

None

PATIENT A (DR. X)

66 yo M VAcc 20/25 OD, 20/30 OS +2.00 OU IOP 23/22, post-dilation: 28/30 @11 AM Gonioscopy: narrow, occludable angles OU Lens: Trace NS C:D: 0.3 OU Scheduled LPI OS then OD

PATIENT A (DR. Y)

@ 6PM, c/o pain OS VA CF OS IOP 52 Started Diamox, PF, Combi, Trav Z, Pilo 2% IOP down to 34 Scheduled LPI the next AM

PATIENT A (DR. X)

LPI OS VA 20/400 IOP 24 On Diamox, PF, Combigan, Trav Z, Pilo 2% Sent to see me that day

PATIENT A

VA OS 20/400, 3+ K edema IOP 27 On Diamox, PF, Combigan, Trav Z, Pilo 2% LPI was not patent After gonioscopy OU AS-OCT OU

PATIENT A AS-OCT OD-OS

PATIENT A

D/C Diamox, Pilo, Trav Z IOP 17

The next three weeks VA improved to 20/40 IOP 27-38 On Combigan, PF, Diamox

LASER PERIPHERAL IRIDOTOMY(LPI)

Provides an alternate route for the aqueous in the posterior chamber to enter the anterior chamber

LasersArgonNd:YAG

(Incisional iridectomy if no access to lasers)

LPIIndications:

1. Pupillary blockPhakicAcIOLIntraocular CLSilicone Oil

2. Eyes at risk for pupillary blockNarrow angle and attack in the fellow eye50% of the fellow eye will develop acute ACG*

3. To rule-out pupillary block Plateau iris syndrome

.

* Lam DSC et al. Glaucoma. Vol 2. Saunders; 2009:(65)61-69

LPI

Indications for prophylactic LPI

1. Symptoms of subacute ACG2. Appositional closure on gonioscopy3. PAS4. Elevated IOP and closure of angle with dilation 5. Inability to be evaluated promptly

LPI

Contraindications:

1. Significant corneal edema2. Flat AC3. Completely closed angle4. ACG not caused by pupillary block

Neovascular glaucomaIridocorneal endothelial (ICE) syndrome

LPI (NON-ACUTE)

Plan for procedure first thing in the morning and early in the week.

Preoperative treatment:lopidine (brimonidine) + Pilocarpine 1% 30 minutes before

Postoperative treatment:1. lopidine (brimonidine) after2. IOP check 1 hour after treatment 3. Pred acetate 1% qid for 1 week

LPI (NON-ACUTE)

On follow-up

1. VA, IOP, AC and patency of LPI2. Gonioscopy3. Schedule for mydriatic provocative testing

Dilate with Tropicamide 1% (8AM)Recheck IOP after lunch

LPI (ACUTE)

NKDA or no contraindications to meds

1. acetazolamide 500 mg PO x 12. Combigan q5min X 33. Azopt q5 min X 34. Pilocarpine 1% X 1 (after #2 and #3)

LPI (ACUTE)

Sulfa allergy or unable to take PO meds

1. Paracentesis (5% betadine and antibiotics)

2. Combigan q5min X 33. Pilocarpine 1% X 1 (after #2)

LPI

Laser technique*:

1. Contact lens (Abraham)

2. Laser settings:

Argon: 800-1000mW50μm 0.02-0.1 sec

Nd:YAG: 3-8 mJ1-3shots/pulse

*Allingham et al. Shield’s textbook of glaucoma. 5th ed. Pg 538-540.

LPI

Laser technique:

1. In base of a peripheral iris cryptat 12, near 9 or 3:00.

2. With Silicone oilat 6:00

3. Endpoint:Pigment stormVisualizing

anterior lens capsule or vitreous faceIris transillumination

LPI

Complications:Transient IOP spikeHyphemaAnterior uveitisCorneal epithelial and endothelial burnsCataract formationPupillary distortionMonocular diplopia and glareClosure of iridotomyMalignant glaucomaUnable to break pupillary block

LPI

Difficult in ACG due to thick iridies Increased iris thickness and association with PACG*

*Aung et al. Br J Ophthalmol 2011;95:46-50.

PATIENT A AS-OCT OD-OS

PATIENT A

Treatment options: Peripheral iridoplasty Trabeculectomy PhacoTrab Phaco with possible goniosynechialysis

PATIENT A

Phaco OS POD #1

Vasc 20/50 IOP 12 PF, Combigan

POW #1Vasc 20/30 IOP 14 on PF

POM #1Vasc 20/20 IOP 22 on PF

PATIENT A

OD Vacc 20/30 IOP 29, no eye meds

What to do? Observe? LPI? Peripheral Iridoplasty? Phaco?

PATIENT A

Phaco OD POD #1

Vasc 20/25 IOP 22

POW #1 Vasc 20/20 IOP 16

POM #1 Vasc 20/20 IOP 18

PATIENT A AS-OCT OS BEFORE & AFTER CE

PATIENT A AS-OCT OD BEFORE & AFTER CE

PATIENT A AS-OCT 3D OD BEFORE & AFTER CE

LEARNING OBJECTIVES

Not all AACG are pupillary block Perform LPIs early in the day and week Prepare to take the patient to surgery if laser

fails Unless it’s an emergency, do not perform an

LPI on the second eye until the first eye is healed.

THANK YOU